1. C. difficile prevention & treatment Probiotics, antibiotics
& fecal microbiota transplantation
The scoop on therapeutic poop
Monika Fischer, MD, MSCR
Assistant Professor of Clinical Medicine

2. Disclosure
No conflict of interest

3. Clostridium difficile infection (CDI)
Traditional medical school fact: Clostridium difficile pseudomembranous colitis is a Clindamycin aftermath and highly treatable with metronidazole
C. difficile infection (CDI) associated with numerous other antibiotics and often resistant
to metronidazole
The traditional medical school fact that C. difficile is pseudo mebranous colitis needs revision

4. Epidemic strain of C. difficile
Beginning of 2000
Epidemic strain of C. difficile
US rates hospital discharges with CDI doubled between 2000 and 2008
Increased need for ICU stay and prolonged antibiotic courses to clear infection
High colectomy rates (10%)
High case mortality: 7500/year (10-fold increase since 1999)
Refractory disease in low risk populations
Beginning of 2000, hyper virulent strains emerged appeared to be linked to increased use of fluoroquinolones and cephalopsporins.
The epidemic strains have caused more severe and refractory colitis, increased the need for ICU stay and required longer Abx therapy. We have witnessed an unprecedented colectomy rate and case mortality. Populations previously considered to be low risk are increasingly becoming afflicted with refractory c. diff. The increase in incidence and severity of CDI is largely attributed to the emergence of a new strain, designated restriction endonuclease analysis type BI, North American pulsed-field electrophoresis type 1 (NAP1), PRC ribotype 027 - . 4

5. BI/NAP1/027 Linked to widespread fluoroquinolone and cephalosporin use
High-level fluoroquinolone resistance
“Hypervirulent”
18-fold more toxin A & B
Binary toxin: Improved toxin-binding and translocation into the cells
The mechanism of action of these hypervirulent strains characterized and BI/NAP1/027 has been shown to the be result Several characteristics found in BI/NAP1/027 contribute to its hypervirulence:
Polymorphysm in an important toxin production downregulatory gene, tcdC resulting in 18 fold increased toxin production c/w non-epidemic strains
Presence of the gene producing binary toxin: toxin with dual function, enzymatic component and membrane altering component/transport component which facilitates translocation of the bacterria into the cells
high-level fluroquinolone resistance: explain why this strain is selected over other non-epidemic strains of c. diff in the setting of fluoroquinolone use
But, there are other reasons for the c. diff epidemic

6. C. difficile infectious inoculum is 10 spores
Alpha- Defensins
Poutanen SM et al. CMAJ. July 6,2004;171(1).

7. Host factors Age ≥ 65 year Immunosuppression PPI use ≥ 3-fold
recipients of organ transplants (3-11%), chemotherapy, corticosteroids, HIV, IBD, ESRD, ESLD
PPI use ≥ 3-fold
Hospitalization, long-term care facilities
After 1 week 13%, after 4 weeks > 50% colonization rate
Previous CDI
More than half of C. diff burden originates from healthcare facilities. With each additional day of hospitalization the risk of CDI increases. It is estimated that 13% of patients get colonized with c. diff during a 1-2 week hospital stay while more than 50% get colonized if treated in the hospital for more than 4 weeks

8. Prevention: infection control
Early detection
High index of suspicion in patients with risk factors
Empiric therapy should be started regardless of laboratory testing
Use of best diagnostic test for toxigenic C. diff. with a rapid turn-around time (PCR)
Repeat stool testing is discouraged
< 5% chance for positive test
Routine screening in hospitalized patients without diarrhea is not recommended

9. Hospital-based infection control program
Antibiotic stewardship
Contact precautions should be maintained at a minimum until the resolution of the diarrhea
Private rooms
Hand hygiene: soap (preferably 4% chlorhexidine) & water. Alcohol based antiseptic does not kill C.diff spores!
Barrier precautions (gloves & gowns)
Hospital based infection control program can help to decrease the incidence of c. diff. Antibotic use is the strongest risk factor for c.diff. Any antibiotic can cause CDI but clindamycin, cephalosporins and fluorokinolones pose the highest risk. In one study, antimicrobial stewardship decreased CDI incidence by 60 %.
C. Difficile can be cultured from the surfaces of rooms of asymptomatic patients but to much lesser degree than from the rooms of symptomatic pts. Patients skin surfaces may contain c. diff spores up to 2 weeks after the resolution of the diarrhea---- some institutions use contacts precautions for the entire duration of the hospitalization.
Hand hygiene and is the cornerstone of prevention of nosocomial infections including c.diff.

10. Prevention: infection control
Single use disposable equipment
Environmental disinfection with10% bleach (5,000 p.p.m. chlorine) for at least 10 minutes
Infection control “bundle” decreased CDI hospital rates by 33% (7.2/1000 to 4.8/1000)
In one large prospective study, infection control bundle consisting of education, early case finding, reinforcement of contact precautions decreased hospital c. diff rates by 33%

11. Prevention: Probiotics
Annals 2012 SER and Meta-analysis of 20 trials: Probiotics given for the duration of the antibiotic therapy or up to 2 weeks after reduced the incidence of CDI by 66%
No difference in outcome
Between species: Bifidobacterium, Lactobacillus, Saccharomyces, or Streptococcus
Single species vs. mixture
Adults vs. children
Lower or higher doses (<10 billion CFU/d vs.≥10 billion CFU/d)
The authors concluded that moderate-quality evidence supports a large protective effect of probiotics in preventing CDAD. Given the low cost of probiotics and lack of side-effects, there seems to be little reason not the encourage the use of probiotics in paitents who are at risk for C. diff.
Interestingly, ACG practice guidelines published in 2/2013 (referenced in your handout) does not recommend probiotic use in the prevention of CDI due to insufficient evidence

12. Treatment: supportive care
Any inciting antimicrobial agent should be discontinued
Maintain enteral nutrition
Fluid resuscitation, electrolyte replacement
DVT prophylaxis
Anti-motility agents are allowed but only in combination with medical therapy
Maintenance of oral or enteral feeding is important in the absence of ileus or significant abdominal distention as fermentable carbohydrates are crucial for colonic microbiota and contribute to restoration of microbial communities. In addition to fluid resuscitation and electrolyte replacement ,we should not forget about DVT prophylaxis: paitent with C. diff ( especially with severe cdi) at at high risk for thromboembolic events similarly to IBD patients. The use of antimotility agents was discouraged in the past due to concerns of toxic megacolon. A recent summary to studies concluded that anti-diarrheals do not cause harm as long as they are used on conjunction with c. diff therapy

13. Treatment: antibiotics
Patients with mild-to-moderate CDI should be treated with metronidazole 500 mg po tid for 10 days
Patients with severe CDI should be treated with vancomycin 125 mg po qid for 10 days
Failure to respond to metronidazole therapy within 5-7 days should prompt change to vancomycin
ACG guidelines 2013

14. Patients with ileostomy, Hartman’s pouch, or colon diversion
Vancomycin via enema should be included in the treatment
Oral vancomycin can’t reach the disconnected segments
Metronidazole as adjunctive therapy: colonic excretion is high across the inflamed mucosa but drops dramatically once mucosa starts to heal

15. CDI severity
Mild-to-moderate: diarrhea ± any other sign/symptom - not meeting criteria for severe
Severe: serum albumin< 3g/dl plus one of the following
WBC≥ 15,000
Abdominal tenderness
ACG guidelines 2013

16. Severe and complicated CDI
Any of the following attributable to CDI:
Admission to ICU
Hypotension
T≥ 38.5 °C
Ileus or significant abdominal tenderness
Mental status changes
WBC ≥ 35,000 or ≤ 2,000
Serum lactate level > 2.2 mmol/L
End organ failure
ACG guidelines 2013

17. Severe and Complicated CDI
Vancomycin 500 mg po qid plus metronidazole 500 mg iv q 8 hrs, and vancomycin per rectum (500 mg in 500ml saline as enema) qid (patients with ileus)
Consult surgery: colectomy vs. loop ileostomy with lavage and vancomycin flushes
Fidaxomicin po and tigecycline iv.
((Fecal transplant?))
ACG guidelines 2013

18. Special situations C. diff can cause enteritis and pouchitis!
Pregnancy and breastfeeding: Oral Vancomycin
IBD
All patients with IBD flare need testing for c.diff – empirical therapy
Highest risk with corticosteroid use > 3-fold
Reduced dosing of corticosteroids
Immunosuppression can be maintained but escalation should be avoided
Initiation of anti-TNF 72-hrs after starting therapy for CDI
C. diff can cause enteritis and pouchitis!
Metronidazole is not recommended – first trimester exposure causes facial abnormalities--- it crosses the placenta and is detected in the breast milk
2-fold increase in mortality with severe colitis , higher colectomy rate

19. Treatment of Recurrent CDI
ACG guidelines 2013
Repeat metronidazole if the first epidose was treated with metronidazole
Treat with vancomycin pulse regimen for severe or if the first episode was treated with vanco
Vancomycin 125 mg po qid for 10 days followed by 125 mg every 3 days for 10 doses
Consider FMT for the third recurrence

20. Recurrent C. difficile infection
25% of patients have a recurrence after the initial treatment
Patient with first recurrence have a 35-45% chance for second recurrence
With subsequent recurrence: risk > 50%
Antibiotics are not very helpful
Treating recurrent c.diff is a tough task to tackle:
Kelly and Lamont. NEJM 2008

21. After emergence of BI/NAP1/027 high failure rates with metronidazole and high recurrence rates with both metronidazole and vancomycin
The published treatment rates with meteronidazole and vacomycin were similar before After 2000, the treatment failure rate rose to 18% with metronidazole while remained 3% with vanco.
This rise in treatment failure coincided with the dramatic increase in CDI incidence and the emergence of the epidemic strain NAP1. These issues resulted in an ongoing debate about whether vanco is superior to metronidazole and should therefore be used as first-line despite the concerns about the higher cost and the possibly increased nosocomial vancomycin resistance, particulary VCE.
Relapses occur at 25% of patients that are adeQUATELY treated with these agents. Relapses usually occur within the first several days after the completion of antimicrobial therapy
Aslam S. et al. Lancet Infec.Dis : (pooled results from 25 studies)

22. Fidaxomicin New bacteriocidal antibiotic
Poorly absorbed narrow-spectrum macrolide
FDA approval for CDI in 2011

23. Fidaxomicin vs.Vancomycin
In an industry sponsored trial of over 600 patients, a cure was achieved in 88% of the Fidaxomicin grogu and 86% of vancomycin group. Recurrence rates were 15% with fidaxomycin and 25% with vancomycin. This finding was confirmed in non-industry-sponsored studies.
is an oral minimally absorped macrocyclic antibiotic) became the second drug approved by the FDA for CDI in 5/2011. Promising aspects of the drug is that it has bactericidal effects on clostridium species and has limited effect of the bacterial flora. The initial cure rates were similarly high with fidaxomicin and vanco. However, fidaxomycin was associated with significantly lower rate of CDI. Unfortunately, this was was not true for the epidemic NAP1 strain.
Louie TJ. NEJM. 2011;364:422-31

24. Vancomycin vs. fidaxomicin for the first recurrence of CDI
Recurrence of Clostridium difficile infection (CDI) occurs in approximately 25% of successfully treated patients. Two phase 3 randomized, double-blind trials were conducted at 154 sites in the United States, Canada, and Europe to compare fidaxomicin vs vancomycin in treating CDI. Patients with CDI received fidaxomicin 200 mg twice daily or vancomycin 125 mg 4 times daily for 10 days. The primary end point was clinical cure of CDI at end of treatment, and a secondary end point was recurrence during the 28 days following clinical cure. In all, 1164 subjects were enrolled, of which a subgroup of 128 in the per-protocol population had another recent episode of CDI prior to the CDI diagnosis at study enrollment. In the analysis of this subgroup, initial response to therapy was similar for both drugs (>90% cure). However, recurrence within 28 days occurred in 35.5% of patients treated with vancomycin and 19.7% of patients treated with fidaxomicin
Cornelly OA. Clin Infect Dis :

25. The New Kid on the block: Stool
FMT is placement of suspension of fresh stool harvested from healthy individual into the gastrointestinal tract of an individual with CDI
Through standard colonoscopy
Rectal enema
NJ and NG tube
Alternative therapy, but by no means new…
As is turns out , FMT is a great and highly efficacious alternative therapy BUT not certainly not new

26. A 1,700-year-old method
4th century China: human fecal suspension by mouth “yellow soup“ for food poisoning, severe diarrhea
4th century in China, Ge Hong, a well-known traditional Chinese medicine doctor, described the use of human fecal suspension by mouth for patients who had food poisoning or severe diarrhea
in the Ming dynasty of the 16th century, Li Shizhen described a series of prescriptions using fermented fecal solution, fresh fecal suspension, dry feces, or infant feces for effective treatment of abdominal diseases with severe diarrhea, fever, pain, vomiting, and constipation in the most-known book of traditional Chinese medicine, “Ben Cao Gang Mu” (Compendium of Materia Medica). For aesthetic considerations, the herb doctors did not label the fecal suspension by its original name, but called it yellow soup or used other exhilarating names

27. Fecal transplantation in veterinary medicine since the 17th century
Transfaunation
Horses with diarrhea per rectum
Cattle per os as rumen
The definition for transfaunation is a symbiotic fauna (usually mutualistic protozoa) transfer from one host to another.
The first fecal transplantation in humans was performed in 1958 for diarrhea. However, and it has been performed in animals for more than 100 years. For example, veterinarians perform fecal transplantation to treat horses with diarrhea by infusing stool from healthy horses into the rectum of the sick animals, and they administer rumen fluid to cows and alpacas to treat a variety of conditions. The latter application is referred to as transfaunation.
Although, it was found to be very efficacious in last 10 years in multiple case reports, it has been slow to gain acceptance. Besides the undeniable “ ick factor” The reason for this the need to screen donors, lack of reimbursement among providers and patients.

28. Modern history of human fecal transplantation
1958 Ben Eiseman reported “miraculous cure” with FMT in 4 patients with fulminant pseudomembranous colitis
“re-establish the balance of nature”
“immediate and dramatic” responses
“this simple yet rational therapeutic method should be given more extensive clinical evaluation”
In the modern history“re-establish the balance of nature” within the intestinal flora to correct the disruption caused by antibiotic treatment. They reported “immediate and dramatic” responses and concluded that “this simple yet rational therapeutic method should be given more extensive clinical evaluation.” During the ensuing 50 years, the association between Clostridium difficile infection and pseudomembranous enterocolitis was established, and effective antimicrobial treatments were identified. Despite these advances, C. difficile became the most commonly identified cause of nosocomial infectious diarrhea in the United States. During the past decade, there has been an alarming increase in the incidence and severity of this disorder, with associated increases in mortality and economic cost

29. Explosion of FMT case studies since 2010
> 500 cases reported with 92% success rate with the first treatment and up to 98% if a second infusion was necessary
Longest follow up 17 months of 77 pts – zero recurrence without antibiotics (all recurrences related to antibiotic use 8/30)
97% of patients would undergo another FMT if needed
57% voted for FMT as their preferred first treatment option
all recurrences related to antibiotic use (unrelated to C.diff) 8 out of 30 treated with antibiotics among 77 pts. 26% of those who were treated with Abx.
Brandt, L. ACG. 2012

30. Vancomycin therapy for 14 days
The last impediment is addressed by Nood and colleagues from the Netherlands.
Randomized, controlled but unblinded study where the investigators compared duodenal infusion of donor feces after vancomycin therapy with vancomycin therapy alone vs vancomycin therapy with bowel l
Duodenal infusion of donor feces after vancomycin for 4 days and bowel lavage
Vancomycin therapy for 14 days
Vancomycin therapy for 14 days plus bowel lavage on day 4-5

31. 15 13
Initially the plan was to randomized 120 patients. However, The trial was closed early to new enrollment after the only 43 patients---- the interim analysis of the safety board because almost all paitent had recurrence in the control groups. 94% successrate confirmed the anecdotally reported 92% success rate via colonoscopy or enema
Nood et al
NEJM. Jan. 2013

32. Microbiota diversity increases after stool transplant
Nood
NEJM
2013

33. Who should be treated with FMT?
After 3 episodes or after failure of vancomycin pulse regimen (ACG guidelines)
L. Brandt recommendations:
First line therapy in severely ill patients
FMT may be preferred for the first episode of CDI because antibiotic perturbs the microbiota and may lead to antibiotic resistance
Brandt, L. JCGE. 2011

34. Risks of FMT Colonoscopic perforation
Transmission of infections and other diseases
Long-term risk?
Increased incidence of autoimmune conditions: 4 out of 77 patients developed peripheral neuropathy, Sjӧgren syndrome, RA, ITP within median 17 months f/u
Brandt LJ. ACG. 2012;107:

35. Donor selection
Intimate contacts, family members to mitigate risk of transmissible diseases
But, results with “standardized” or “universal” donors are similarly excellent with fresh or frozen/thawed preparations
Patients are advised to soliticit donors from well-known family members to decrease the risk of transmissible diseases.

36. Donor screening Stool Blood Bacterial culture
Ova & parasites including Giardia, Cryptosporidium, Cyclospora, Isospora
C.difficile
H. pylori
Blood
Hepatitis A, B, C
HIV 1/2
Syphilis

37. Donor selection Exclusion criteria
IBD, IBS, functional diarrhea or constipation, h/o GI malignancy
Antibiotic use within 3 months
Systemic chemotherapy or immunosuppression within 1 year
Known HIV, hepatitis B and C, illicit drug use, incarceration, tattoo/piercing within 6 months

38. Donor’s badge

39. Which route of administration is the best?
Nasogastric
Nasoenteric tube
EGD
Quick
Convenient
Inexpensive
Avoid colonoscopy
Fecal enemas
Easy to administer
Cheap
Can be performed at home
Via colonoscopy
Highest patient acceptance
Ability to assess disease severity and colonic mucosa
SER 1: colonoscopy and enema (required repeated infusions) with superior cure rate > 85% vs. 76% upper GI route
SER 2: colonoscopy superior 93% vs. 85% nasogastric tube

40. FMT via colonoscopy at IU

41. FMT at IU Hospital Stops vancomycin 36-48 hrs before FMT
Patient preps for colonoscopy
Stops vancomycin hrs before FMT
Fresh stool (not older than 6 hrs) emulsified in the endo suite and infused into the terminal ileum or right colon
Patient receives Imodium and observed for 2-3 hrs.
Environmental cleaning at home
CPT code 44705
Bakken J, Borody T, Brandt L et al. Treating Clostridium difficile Infection With Fecal Microbiota Transplantation. Clinical Gastroenterology and Hepatology, December 2011, 9(12):

42. Why and how does FMT work?
At least in 1 study showed persistance of donor flora at 24 weeks

43. Nat. Rev. Gastroenterol. Hepatol.
Borody, T. J. & Khoruts, A. (2011)
Nat. Rev. Gastroenterol. Hepatol.
CDI causes severe diarrhea, intestinal inflammation and cell death as a result of toxin-mediated infection with the pathogenic bacteria. Patients with CDI are typically treated with antibiotics, which not only kill the pathogenic C. difficile but also exhibit activity against the dominant colonic microbiota phyla. Incomplete antibiotic eradication of C. difficile can result in recurrent CDIs. Transplantation of fecal microbiota from a healthy donor into an individual with CDI can restore the healthy gut microbiota in the patient's diseased colon, leading to resolution of symptoms

44. Mechanism of action
FMT is introduction of a complete, stable community of gut-organisms to repair or replace the disrupted native microbiota
Reestablishment of the host defense against C. difficile
Engraftment of the donor microbiota is durable
At least in 1 study showed persistance of donor flora at 24 weeks

45. Bacterial fingerprints of the donor and recipient stool before and after FMT
Terminal-restriction fragment length polymorphism analysis
The intestinal flora of healthy individuals is dominated by Bacteroidetes and Firmicutes. Composition and species richness of microbiota is in patients with CDI is markedly different.
Single case of successful FMT in a 61 yr old patient with severe recurrent CDI of 8 months duration with 27 kg weight loss and multiple hospitatlization for iv hydration. on nitazoxanide before FMT. Received stool from a hsuband of 44 years. F/u for 6 months--- 1 formed BM daily.
The microbial fingerprints from the pt 7 days before the transplant were completely different from those of the donor day 1. The patient’s dominant strain was clostridium, veillonella lactobacillus and streptococcus---- most of these strains were entirely absent or at least not abundant on the donor’s stool. At day 14 and 33 after FMT show that the patient fecal flora retained characteristics of the donor although small changes can be seen. Bottom line is that bacteriodetes and firmicutes ( Clostridium an Bacilli) remained the dominating strains and certainly restored normal bowel function in this case.
Many Firmicutes produce SCFAs and strong evidence suggest SCFA especially butyrate are crucial in maintaining the integrity of colonocytes and in reducing inflammation.
This is only a single case but similar results were presented from numerous patients at DDW in 5/2012.
Khoruts A. J Clin Gastroenterol. 2010;44:
Donor Day 0; Patient Day 14; Patient Day 33

46. Probiotics in the treatment and recurrence prophylaxis of CDI
Limited evidence for adjunct probiotics to reduce risk of recurrence
S. boulardii showed efficacy in few trials reducing recurrence rate to 35% vs. 65% but only in patients on high dose vancomycin
Why probiotics don’t work?
Insufficient CFU count
Not the right species or mixture
Wrong media (milk) to culture probiotics
This naturally raises the question: Why probiotics do not work?

48. murine model of C. difficile colitis
Animal experiment –
murine model of C. difficile colitis
Mice treated with Clindamycin for 7 days
Infected with C. difficile BI/NAP1/027 from hospitalized patients
Mice developed severe colitis
Dysbiosis
Reduced diversity
Reduced Bacteriodetes and Firmicutes
Increased opportunistic pathogens (Klebsiella, E. coli, Proteus mirabilis, Enterococcus faecalis)
Up-regulated pro-inflammatory genes
Lawley et al. PLOS 2012

49. 5. Mice treated with vancomycin Suppression of C. difficile shedding
6. Relapse upon cessation of therapy
7. FMT using healthy mice stool per os
Durable suppression of C. difficile shedding for several months resolve disease and contagiousness
Lawley PLOS 2012

50. Targeted bacteriotherapy
Instead of stool from healthy mice A mixture of six phylogenetically diverse bacterial species including obligate and facultative anaerobes Bacteriodetes and Firmicutes cured CDI in mice with severe colitis infected with BI/NAP1/027
Lawley, T. 2012

51. Stool substitute to ‘rePOOPulate’ the gut
Made from purified intestinal bacterial cultures derived from a healthy donor after recovering 33 isolates using “Robogut”
Petrof, EO. Microbiome 2013.

52. Future ?
Custom designed pill of selected micro-organisms to restore the balance of the microbiota or correct a deficiency of a specific commensal organism curing a disease or reversing a metabolic condition

53. Summary of FMT
FMT is a simple, acceptable and currently the most efficacious treatment for recurrent CDI--- may play a role in the treatment of variety of GI and non-GI diseases
FMT via the upper tract seems to be less efficacious than via the lower tract
Long-term safety remains unknown
The Future… “Artificial stool” or targeted bacteriotherapy

54. References
Surawicz, Ch. Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficle infections. AJG. 2013
Johnston, B. Probiotics for the prevention of Clostridium Difficile-Associated Diarrhea. Annals. 2012
Van Nood, E. Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. NEJM. 2013

55. References
Brandt, L. Intestinal Microbiota and the Role of Fecal Microbiota Transplant in the Treatment of C. difficile Infection. AJG. 2013
Bakken, J. Treating Clostridium difficile Infection with Fecal Microbiota Transplantation (the Fecal Microbiota Transplantation Workgroup). CGH. 2011
Brandt, L. An overview of fecal microbiota transplantation. Gastrointest. Endosc. 2013